A “Healthy Immigrant Effect” or a “Sick Immigrant Effect ...ftp.iza.org/dp9338.pdf · 2 A...

Forschungsinstitut zur Zukunft der Arbeit Institute for the Study of Labor DISCUSSION PAPER SERIES A “Healthy Immigrant Effect” or a “Sick Immigrant Effect”? Selection and Policies Matter IZA DP No. 9338 September 2015 Amelie F. Constant Teresa García-Muñoz Shoshana Neuman Tzahi Neuman

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Forschungsinstitut zur Zukunft der ArbeitInstitute for the Study of Labor













A “Healthy Immigrant Effect”or a “Sick Immigrant Effect”?Selection and Policies Matter

IZA DP No. 9338

September 2015

Amelie F. ConstantTeresa García-MuñozShoshana NeumanTzahi Neuman

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A “Healthy Immigrant Effect” or a “Sick Immigrant Effect”? Selection and Policies Matter

Amelie F. Constant

George Washington University, Temple University and IZA

Teresa García-Muñoz

University of Granada

Shoshana Neuman

Bar-Ilan University, CEPR and IZA

Tzahi Neuman

Hadassah-Hebrew University Medical Center

Discussion Paper No. 9338 September 2015


P.O. Box 7240 53072 Bonn


Phone: +49-228-3894-0 Fax: +49-228-3894-180

E-mail: [email protected]

Any opinions expressed here are those of the author(s) and not those of IZA. Research published in this series may include views on policy, but the institute itself takes no institutional policy positions. The IZA research network is committed to the IZA Guiding Principles of Research Integrity. The Institute for the Study of Labor (IZA) in Bonn is a local and virtual international research center and a place of communication between science, politics and business. IZA is an independent nonprofit organization supported by Deutsche Post Foundation. The center is associated with the University of Bonn and offers a stimulating research environment through its international network, workshops and conferences, data service, project support, research visits and doctoral program. IZA engages in (i) original and internationally competitive research in all fields of labor economics, (ii) development of policy concepts, and (iii) dissemination of research results and concepts to the interested public. IZA Discussion Papers often represent preliminary work and are circulated to encourage discussion. Citation of such a paper should account for its provisional character. A revised version may be available directly from the author.

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IZA Discussion Paper No. 9338 September 2015


A “Healthy Immigrant Effect” or a “Sick Immigrant Effect”? Selection and Policies Matter*

An extensive body of research related to immigrants in a variety of countries has documented a “healthy immigrant effect” (HIE). When immigrants arrive in the host country they are healthier than comparable native populations, but their health status may deteriorate with additional years in the country. HIE is explained through the positive self-selection of the health of immigrants and the positive selection, screening and discrimination applied by the host countries. In this paper we study the health assimilation of immigrants within the context of selection and migration policies. Using SHARE data we are able to compare Israel and Europe that have fundamentally different migration policies. Israel has virtually unrestricted open gates for Jewish people around the world, who in turn have ideological rather than economic considerations to move. European countries have selective policies with regards to the health, education and wealth of migrants, who self-select themselves. Our hypothesis is that the HIE, evidenced in many countries will not be found in Israel. Instead, immigrants to Israel may arrive with lower health than that of natives and improve their health with residence in the country, due to the universal health coverage and generous socio-economic support of the government. Our results provide evidence that a) immigrants to Israel have compromised health and suffer from many health ailments upon arrival, making them less healthy than comparable natives. Their health does not improve for up to twenty years of living in Israel, after which they become similar to natives; b) immigrants to Europe have better health than natives upon arrival and up to eleven years since arrival in the host country, after which they are not significantly different than natives. Our results are important for policy. JEL Classification: C22, J11, J12, J14, O12, O15, O52 Keywords: self-reported health status, immigration, Europe, Israel, older population, multilevel regression, SHARE Corresponding author: Shoshana Neuman Department of Economics Bar-Ilan University 52900 Ramat-Gan Israel E-mail: [email protected]

* We are grateful for comments and critical questions by the Annual Migration Meeting participants in Dakar, Senegal, April 2015. We have also benefited from discussions with Klaus F. Zimmermann. Part of this work was carried out at IZA when S. Neuman and A. Constant were visiting together.

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A “healthy immigrant effect” or a “sick immigrant effect”?

Selection and policies matter


An extensive body of research related to immigrants’ health in a variety of countries

(including Australia, Canada, France, Germany, Spain, Sweden, the United Kingdom,

and the United States) has documented that when migrants first arrive in the host

country they are healthier than comparable native populations; they may also be

healthier than the population in their country of origin, as they are not a random sample

of the left-behind. This phenomenon has been labeled as the “healthy immigrant effect”

(HIE). In most countries the HIE dissipates after the first ten years since arrival.

Several explanations have been proposed to explicate the immigrants’ health advantage

upon arrival. The theory of positive self-selection of immigrants posits that only the

healthiest and most motivated individuals choose to move and undergo the traumatic

experience of migration to a new country; less healthy and weaker individuals stay

behind. ‘Survival of the fittest’ predicts that only the most healthy will be able to survive

the tribulations and stress of the move and proceed with the struggle of acculturation in

the new society and assimilation into a new labor market. On top of self-selection, in

many countries, there is another level of selection imposed by the host country’s

migration policies. Accordingly, host countries screen prospective immigrants for health

and prefer the wealthier and more educated immigrants. As wealth and education are

usually positively correlated with health, the outcome is that new immigrant arrivals

have a health advantage over natives.

Another related explanation is that medical examinations by immigrant authorities in the

host countries are conducted at the border to further screen out less healthy immigrants

in order to reduce public health menaces (especially relating to communicable diseases)

and lessen the burden to the healthcare services. Screening started in 1887 in the United

States (Evans, 1987) and is still the norm in Canada, Australia and other countries

(Chiswick, Lee and Miller, 2008). There is consensus in the literature that this two-sided

positive selection is a major driving force behind the “healthy immigrant” phenomenon.

A third idea conjectures that diets and behaviors are healthier in many home countries,

including better nutrition and dietary habits, more physical activities, close family and

religious ties, and other socially protective factors that shield migrants and preserve

good health. Finally, it may be that self-reported health conditions are under-reported by

foreign-born populations upon arrival, either because they have not yet been diagnosed,

or because of differences in perceptions about health. Discussion of the various theories

that try to explain the HIE, can be found in: Jasso et al., 2004; McDonald and Kennedy,

2005; Antecol and Bedard, 2006; Biddle, Kennedy and McDonald, 2007; Chiswick, Lee

and Miller, 2008; Neuman, 2014; and Constant et al., 2014.

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It is also reported that the immigrants’ health advantage declines with time spent in the

host country and converges toward (or even falls below) the health status of native

residents. Researchers are puzzled by the subsequent health deterioration and have

offered several explanations, including “negative acculturation”; a natural process of

regression towards the mean as immigrants assimilate and converge toward the health

status of the local population (Jasso et al., 2004); low utilization of healthcare services;

discrimination (stemming from xenophobia, racism and “otherness”) (Grove and Zwi,

2006); poor working conditions and sorting of immigrants into more dangerous and

strenuous occupations (Orrenius and Zavodny, 2009; Guintella and Mazzonna, 2004).

For a review of factors driving the health deterioration and empirical testing, see

Neuman, 2014; and Constant et al., 2014.

Data shortcomings limit the ability to disentangle the roles of the various factors driving

the health advantage of immigrants upon arrival, as well as the health deterioration

process after settling in the host country. The existing literature, however, has made

some efforts to challenge the selectivity hypothesis. Employing the type of entry visa to

Australia as a measure of the degree of selectivity of immigrants, Chiswick et al. (2008)

distinguished between economic (self-selected) migrants and (non-selected) refugees.

Entry health regulations may also be looser for refugees than for economic migrants,

since helping those in distress is the main objective of the refugee policy, leading to very

different host country selection levels. The authors find that immigrant health is indeed

the poorest for refugees and best for economic migrants. Others show that positive

health selection differed significantly across migrant groups and was related to

differences in the socioeconomic profiles of immigrant streams (Akresh and Frank,


Focusing on the self-selection of immigrants in terms of education, which also leads to

earnings’ assimilation as well as it is correlated with health, Cohen and Haberfeld (2007)

compared immigrants from the former Soviet Union (FSU) to Israel and to the United

States, during the time period of 1968-1989. During this period of the Cold War, the

United States opened its doors to FSU immigrants, granting them refugee visas. The

authors suggest that FSU immigrants to the United States have significantly higher

educational attainments and experience faster rates of earnings assimilation in the host

country than their counterparts who immigrated to Israel. The authors present evidence

that positive self-selection is the main reason for these differences.

Israel is a unique country to study in the sense that it does not impose any health

screening on people of Jewish origin who want to migrate to the country. Israel also has

a compulsory and universal healthcare system that provides all its residents with medical

services. In fact, all Jewish migrants receive medical care and health insurance upon

arrival. Moreover, Israel has actively supported the transportation of migrants and

airlifted many of them.

In this study we propose to test the HIE in the context of selection and migration

policies. Taking advantage of the SHARE data we examine the self-reported health

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(SRH) status of immigrants and natives and compare their outcomes between Israel and

sixteen European countries.

In the next section some stylized facts about immigration to Israel are presented,

followed by a brief description of the SHARE data base used for the comparative study.

A comparison of the health status of immigrants to Israel, versus immigrants in

European countries is then presented. The variable we study is the self-reported health

scores (ranging from 1 (poor) to 5 (excellent)). Multivariate regression analysis is then

employed in order to control for socio-economic background variables such as age,

education, wealth, marital status, number of children; for personal medical records such

as diseases diagnosed with, medical symptoms, drug use, medical consultation,

hospitalization, quality of eyesight, health risk factors, mobility limitations, cognitive

skills; and for country-level aggregate per-capital GDP (in log) in the European analysis.

After we present and discuss our results, we conclude the study.

Immigration to Israel: Some stylized facts

Israel has always encouraged and assisted the immigration and return migration of

Jewish people; it has also devoted time and money to the absorption process1 of these

immigrants as part of a pro-immigration ideology and policy. Israel’s raison d’etre has

been and remains the in-gathering and retention of Jewish immigrants and the forging of

these diverse elements into a unified nation. It is a country established for and

administrated by immigrants from diverse countries and origins. Israel has a unique

immigration policy that opens the gates of the country to everybody who is Jewish or

has a Jewish ancestry. The state is legally committed to the absorption of any applicant

of Jewish origin. The idea behind the “Law of Return”, which was passed in 1950, is

that Israel should become home to all Jews around the globe, who wish to return to their

homeland. The Law states that:

“Each and every Jew has the right to immigrate to Israel.. He will be given an

Immigration Certificate by the Minister of the Interior.. unless he is: acting against the

Jewish people; might endanger the health of the public or the security of the country; or

has a criminal record which might endanger the safety of the public”.

In 1970 the “Law of Return” was extended and the right to immigrate covered also the

children, grandchildren, spouse, and spouses of children and grandchildren of a person

who is Jewish. A generous absorption policy and good public health and education

systems help all immigrants to settle and adjust to the Israeli labor market and society.

Many immigrants may also have family who arrived in previous waves of immigration

in the country, who are able to help them settle and assimilate. Non-Jews, too, may

immigrate, but in accord with international practice, this right is restricted (Neuman,


1 Absorption is the word denoting a profound and lasting integration of all Jewish people in Israel.

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Indeed, Israel witnessed major waves of immigration. During the first three years of its

statehood (from May 15, 1948 to the end of 1951) mass immigration of 711,000 people

supplemented a population of 630,000; this lead to an annual population growth-rate of

about 24 percent. It is probably the only case in history in which the receiving

population was smaller than the immigration influx. Immigration did not stop after 1952,

but the numbers dropped to several thousands a year.2

During the last decade of the 20th

century, Israel witnessed another impressive influx of

immigrants from the former Soviet Union (FSU). Between 1990 and 1998, with the fall

of the Iron Curtain, the Israeli population of 4.56 million was enriched by 879,486

immigrants; a total population growth-rate of 19.3 percent. In addition, in 1991 under

the “Operation Solomon”,3 about 15,000 Jews were airlifted from Ethiopia in one single

day and settled in Israel (Neuman, 2005).

The Israeli case is also unusual in that its origins are essentially ideological, triggered by

the emergence of the Zionist Movement in Eastern and Central Europe in the last quarter

of the 19th

century. Immigration to the Land of Israel (Palestine) started in 1882, long

before statehood and the establishment of the State of Israel in 1948. Between 1882

and 1947, in successive waves of immigration, some 543,000 Jews immigrated to

Palestine, joining the 24,000 who lived there (Neuman, 2005). While other major

international migration movements were largely economic in nature – the push of

poverty or the pull of expected better standards of living – or have been in response to

persecution, and while all these factors have played some role in immigration to Israel,

the major drive was ideological. The early immigrants were motivated by a commitment

to resettle and rebuild the land of Israel, neglected by centuries of Jewish dispersal

around the world.4

It follows that the self-selection of immigrants in terms of health and

socio-economic dimensions is rather negligible.

Israel’s very generous immigration policy and the absence of any type of health

screening and limitations on one side, coupled with ideological rather than economic

incentives for immigration on the other side, challenge the hypothesis of the “healthy

immigrant effect”, which is believed to stem from selectivity and economic

considerations for immigration. After the fall of the iron curtain, many Russian Jews

with weak and ailing health may have moved to Israel in hopes of improving their

2 Population growth-rates due to immigration varied during the period of the 1950s to the 1990s: from 5

percent in the 1950s and 1960s, they declined to 2 percent in the 1970s and 1980s, and then increased a

little bit to 2.5 percent in the 1990s (Neuman, 2005). 3 Operation Solomon was a covert operation to airlift Ethiopian Jews to Israel due to the dangerous

situation in Ethiopia. 4 While Jewish immigration and the establishment of the State of Israel created the opportunity to

achieve the Zionist Movement's goals, it also intensified the historical Jewish-Arab conflict. As the

Jewish community grew, conflict with the Arab population accelerated. When independence was

declared, the new state was already engaged in the first of a series of wars with neighboring Arab

countries. The War of Independence established the borders of the new state and led to the departure of

a significant portion of the Arab population. As for the end of 2013, the Israeli population of 8,134.5

thousand is composed of a majority of 6,104.5 thousand Jews (75 percent of the total population),

1,420.3 thousand Moslem Arabs (17.5 percent), 160.9 thousand Christians (2.0 percent), 133.4 Druze

(1.6 percent), and 315.4 thousand (3.9 percent) declare to have no religion (Israel, Central Bureau of

Statistics, 2014).

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health. Moreover, it is safe to claim that the generosity of the Israeli immigration policy

and system could even lead to the abuse of the system. For example, elder parents or

sick family members are sent to Israel to receive better health treatment and free the

family from taking care of the elderly and sick. Israel has also experienced mass

migration from tuberculosis-endemic and high HIV-prevalent countries from Africa.

Besides studies in social sciences, studies in medical journals and epidemiology confirm

that immigrants from the former Soviet Union had reported higher rates of diseases and

sub-optimal health (Baron-Epel and Kaplan, 2001), significantly higher BMI, lower

reported “good” health status, higher incidence of heart attack and other chronic diseases

(Manoff et al., 2011).5

In this sense, we could expect negative self-selection of immigrants to Israel with

respect to health. All in all, we could even anticipate, a “sick immigrant effect”, i.e.,

lower health levels of immigrants upon arrival compared to natives, as opposed to what

is experienced in most immigrant-absorbing countries. A comparison of the health of

migrants going to Israel with the health of migrants going to European countries can

therefore shed light on the role of selectivity behind the health status of new immigrants.

The data base

To conduct our comparative study between Israel and other European countries with

respect to the SRH status of immigrants and natives, we use the Survey of Health Aging

and Retirement Europe (SHARE).6 SHARE provides comparable cross-national

individual data for many countries in Europe. It is nationally representative of non-

institutionalized individuals in every country, who are 50 years old and over and their

partners. This age group becomes more and more significant in Europe, given that the

share of the elder population in Europe increases constantly. SHARE has rich

information on the economic and social conditions of individuals as well as their health

and well-being and contains immigrants (persons living in a country where they were

not born) and natives.

Within one decade alone (2002-2012) the number of individuals aged 50 and over

increased by about 30 percent, from 164,000 to 190,000 (Eurostat, 2013). The share of

immigrants in Europe rises as well. The United Nations (2013) report that in 2013

Europe hosted 72 million migrants, constituting 31 percent of the world migrants’ stock,

with almost one third of them (30.6 percent) above the age of 50. In many European

5 Interestingly, these studies do not show excess utilization in health services (Baron-Epel and Kaplan,

2001; Neuman, 2014) nor in emergency room visits or hospitalization (Davidovitch et al., 2013). The risk

of tuberculosis for Israeli natives has also remained very low while by addressing the cultural needs of

these immigrants has effectively controlled the disease among them (Chemtob et al., 2003). 6 For a comprehensive description of the SHARE dataset see: Garcia Muñoz, Neuman and Neuman,

(2014) and Constant et al., (2014).

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countries, more than 10 percent of the populations are foreign-born (immigrants)

(Constant et al., 2014). Moreover, as health starts deteriorating around the age of 50,

studying the health of older natives and immigrants is essential and of great socio-

political importance.

SHARE is a balanced representation of the various regions in Europe, ranging from the

Scandinavian countries (Denmark and Sweden), to Central Europe (Austria, France,

Germany, Switzerland, Belgium, the Czech Republic and the Netherlands) and Eastern

Europe (Poland, Hungary, the Slovak Republic and Estonia), to the South (Spain, Italy

and Portugal). Nineteen countries participated in SHARE, but not all countries were part

of each wave. Israel was included only in the 2nd

wave of SHARE. In addition, the

timing of data collection differs among countries.

Four waves of SHARE, conducted in 2004-2005, 2006-2007, 2008-2009 and 2011-

2012, are now available. The 3rd

wave (SHARELIFE) focuses on the life histories of

individuals. SHARE is an ideal dataset for the study of the health of individuals. It has a

plethora of information on health, socio-economic status and social and family

networks, and contains more than 86,000 individuals. Besides a battery of questions on

the medical conditions and hospitalizations of individuals, SHARE has information on

the self-reported health (SRH) status of the individual. Respondents report their health-

status answering the question “On a scale from 1 to 5, where 1 describes the worst

imaginable condition and 5 the best imaginable condition, how do you rate your health

in general?” This question was designed to make comparisons of populations’ health

among countries comparable.7

Our sample and variables and measures

Our sample consists of Israel and 16 European countries (Austria, Germany, Sweden,

The Netherlands, Spain, Italy, France, Denmark, Switzerland, Belgium, The Check

Republic, Poland, Hungary, Portugal, Slovenia, and Estonia), and complete records on

both immigrants and natives and both men and women. After we account for missing

values, the Israeli sample contains 1,111 individuals and the European sample contains

59,079 individuals (both immigrants and natives). In the Israeli sample, native men are

about 46 percent; immigrant men are 49 percent. In the European sample, men are about

46 percent in both the native and immigrant sample.

Our dependent variable is the subjective metric of SRH. SRH is now commonly used as

a measure of health, based on the finding that individuals are the best evaluators of their

health (Sen, 2002). Numerous studies have demonstrated that SRH is a good proxy for

7 The first wave only asked participants about their SAHS using first the WHO version that rates SAHS

from “very good” to “very bad” and then the US version that rates SAHS from “excellent” to “poor”.

Juerges et al. (2008) find that 69 percent of respondents provided literally concordant answers and only

about one-third provided relatively concordant answers. Moreover, the “two versions were strongly

correlated, had similar associations with demographics and health indicators, and showed a similar pattern

of international variation” (p. 773). In this paper we are using the US version, which was the only one

used in subsequent waves.

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health status measurement, and is also highly correlated with mortality and morbidity

(see Garcia-Muñoz, Neuman and Neuman, 2014; and also Jylha, 2009 – for a

comprehensive review). A more recent medical study underscores the importance of

assessing SRH and treating it like other markers because - for apparently healthy

individuals of both genders - there is an association between inflammation-sensitive

biomarker levels and SRH categories (Leshem-Rubinow et al., 2015).8

We group our independent variables under the following labeling. Demographics (age,

gender, marital status, children), human capital (education), household income, personal

medical information (use of prescription drugs and health facilities), diagnosed health

conditions (heart problem, diabetes, cancer, etc.), smoking, obesity, mobility and

cognitive skills, and macroeconomic information (logarithm of GDP per capita for the

host countries). For the immigrant sample we include years-since-migration (YSM) as a

categorical variable. Table A1 in the appendix provides a detailed description of all

research variables employed.

Data utilization and strategy

We utilize the second wave of SHARE in 2006-2007, because it included Israel. For a

comparable comparison with Israel, we will contrast the data for Israel with equivalent

data for European countries (excluding Israel) that also participated in the 2nd


Findings for European countries based on the most recent 4th

wave (2011-2012), and

also for a pooled sample of the 2nd

and 4th

waves, will also be presented and juxtaposed

to findings for the Israeli case.

We proceed with a cross-country comparison of distributions of raw SRH levels and of

descriptive statistics of health conditions to gain a first approximation of Israeli-

European disparities. The next step is the estimation of SRH equations that include a

battery of health, behavioral, demographic, and socio-economic characteristics as well as

immigration status and years-since-migration.

Distributions of SRH levels – Israel versus European countries

Figure 1 presents the distribution of SRH levels for immigrants and natives within the

Israeli sample. As this histogram clearly demonstrates, a “healthy immigrant effect” is

not evident. On the contrary, we notice a “sick immigrant effect”, meaning that upon

arrival or within the first 10 years since arrival in Israel, immigrants report a much

poorer health status compared to natives. Among those reporting ‘poor’ or ‘fair’ health,

77 percent are immigrants while only 33 percent of natives are in these categories. Only

20 percent of immigrants report ‘good’ health, versus 31 percent of natives. Under ‘very

8 Schneider et al. (2012), using German data showed that socioeconomic and health-related variables have

different impacts on self-assessed health and cautioned to handle heterogeneity with care.

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Wave 2 Europe Wave 4 Europe

Good V. Good Excellent Good V. Good Excellent

good’ health we find only 3 percent of immigrants while we find 28 percent of natives.

Interestingly, not a single one newly arrived immigrant perceives her/his health status as

excellent; natives in this category are 9 percent.

Figure 1 SRH distributions of natives and immigrants by YSM; Israeli sample

Notes Authors’ calculations based on a sample of 1,460 observations included in the 2

nd wave of SHARE,

the only wave that included Israel. There are 945 natives and 515 immigrants (11.6 percent have < 11

YSM; 64.7 percent have 11-20 YSM; 23.7 percent have > 21 YSM).

Immigrants’ health remains inferior to natives’ health also after more than a decade

since migration. We see many more immigrants with low levels of health; only 4.5

percent report ‘very good’ health (compared to 28 percent of natives) and only one

single immigrant (out of 333) reports ‘excellent’ health. There seems to be improvement

in the health status of immigrants after more than two decades of living in Israel; 10

percent even report ‘excellent’ health.

Next, we contrast the SRH distribution within the Israeli sample with parallel SRH

distributions for the sample of European countries. We utilize three alternative samples:

the sample of the 2nd

wave (in which Israel participated) with the exclusion of Israel; the

most recent wave (4th

); and a pooled sample of the 2nd

and 4th

waves (2006-2007, 2011-

2012) excluding repeated observations and Israel.

Figure 2 SRH distributions of natives and immigrants by YSM; European sample


imm. 11-20 ysm

imm.< 11 ysm

imm.> 20 ysm


Poor Fair Good Very Good Excellent

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Notes Authors’ calculations based on: a) the 2nd

wave sample with 30,786 natives and 965 immigrants (7.6

percent with < 11 YSM; 8.8 percent with 11-20 YSM; 83.6 percent with 21+ YSM), b) the 4th


sample with 50,689 natives and 3,955 immigrants (4.1 percent with < 11 YSM; 5.0 percent with 11-20

YSM; 90.9 percent with 21+ YSM), c) pooled 2nd

and 4th

waves with 64,856 natives and 4,469 immigrants

(4.7 percent with < 11 YSM; 5.6 percent with 11-20 YSM; 89.7 percent with 21+ YSM). The pooled

sample is smaller than the sum of the two samples, due to the exclusion of repeated observations.

As it is obvious from Figure 2, the health status of newly arrived immigrants in

European countries is much better than that of natives. A smaller percentage of

immigrants report ‘poor’ or ‘fair’ health, while a larger percentage report ‘good’, ‘very

good’ and ‘excellent’ health. For instance, in the pooled sample, only 15 percent of the

newly arrived immigrants report ‘poor’ or ‘fair’ health, compared to 40 percent of

natives. Many more newly arrived immigrants than natives report ‘good’ health (shares

of 43 and 35 percent, respectively), ‘very good’ health (shares of 27 and 17 percent,

respectively) and ‘excellent’ health (respective shares of 15 and 7 percent). However,

the health status of immigrants deteriorates over time after migration. These findings are

in line with numerous other studies on immigrants’ health by years-since-migration (see

Constant et al., 2014, for a literature review and a comprehensive study of immigrants’

health in European countries).

To extend and complement the SHARE results, which are restricted to individuals ages

50 and older, we derived SRH distributions from the Programme for the International

Assessment of Adult Competencies (PIAAC) dataset, which was conducted in 2011/12.

PIAAC relates to 22 OECD countries and includes individuals aged 16-65. Israeli data

are not available in PIAAC. The results are similar for this extended and more general

age spectrum (and a slightly different country mix). Immigrants who have less than a

decade of YSM are healthier than comparable native residents. As the time living in the

host country lengthens, the reported health status of immigrants deteriorates; after more

than two decades, their health status is inferior to that of the local population.

Unfortunately, the public web of the 1st wave of PIAAC in 2011-2012 does not include

data for Israel. The Israeli case will be considered when Israeli data will be included in

one of the next waves.

Figure 3 SRH distributions of natives and immigrants by YSM; PIAAC/OECD


imm. 11-20 ysm

imm. < 11 ysm

imm. > 20 ysm

Poor Fair Good Very Good Excellent

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Notes Authors’ calculation on a sample of 126,466 natives and 7,820 immigrants (45.0 percent with < 11

YSM; 25.8 percent with 11-20 YSM; 29.2 percent with 21+ YSM).

Summary Statistics of relevant characteristics – Israel versus European countries

Another indication of native-immigrant health disparities can be obtained from an

examination of personal medical information. Table 1 presents descriptive statistics for

natives and immigrants and for both combined together within the Israeli sample.

Starting with the mean of SRH, we see that immigrants on average are almost one

category below natives (2.2 versus 3.07). A focus on comparative objective health

conditions presents very clear and sharp evidence of the inferior SRH of immigrants vis-

à-vis every health factor: they have higher prospects to be diagnosed with major

diseases; consume more drugs; have more medical symptoms and more mobility

limitations; need more physician consultation and hospitalization; have lower cognitive

skills; and suffer more from eyesight problems.

Table 1 Summary statistics, natives and immigrants in Israel

Characteristics Whole sample

Means (st.dev)


Means (st.dev)


Means (st.dev)

SRH (range of 1-5) 2.78 (1.14) 3.07 (1.09) 2.22 (1.01)

Years since migration (YSM) (%) Up to 10 years since migration - - 11.35

11-to-20 years since migration - - 62.17

21 and over years since migration - - 26.48

Arrival years between

1900-1950 - - 8.02 1951-1960 - - 8.59

1961-1970 - - 5.48

1971-1980 - - 3.10

1981-1990 - - 17.95

1991-2000 - - 50.23

2000-2010 - - 6.62

Socio-economics and demographics

Male (%) 47.24 46.34 48.94

Age in years (%)

50-60 34.39 44.57 15.13

61-70 36.69 33.44 42.84

71-80 21.28 18.65 26.27

81+ 7.64 3.34 15.76

Marital status (%)

Married 82.95 81.82 85.07

Widowed 8.52 8.77 8.05

Single/divorced/separated 8.53 9.41 6.682

Number of children 3.10 (2.11) 3.60 (2.29) 2.14 (1.24) Household income centile (1-10) 5.87 (2.95) 6.22 (2.98) 5.21 (2.78)

Education (more than 12 years) 54.04 47.85 65.72

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Characteristics Whole sample

Means (st.dev)


Means (st.dev)


Means (st.dev)

Personal Medical variables

Health conditions; diagnosed with..(%)

Heart problems 14.32 9.94 22.61

Hypertension 41.36 35.41 52.62

Cerebral vascular disease 4.15 2.08 8.06

Diabetes 24.10 22.65 26.83

Chronic lung disease 4.55 2.14 9.09

Arthritis 14.39 11.02 20.76

Osteoporosis 11.75 10.29 14.51

Cancer 5.49 3.58 9.10

Number of medical symptoms 1.73 (2.08) 1.27 (1.59) 2.59 (2.56)

Drug use (number of drugs) 2.10 (1.94)

1.69 (1.59) 2.86 (2.28)

Medical consultation (annual-number) 9.75 (13.68) 8.30 (12.03) 12.48 (16.00)

Hospitalization (%) 13.89 12.43 16.66

Quality of eyesight (range of 1-5) 3.32 (0.96) 3.57 (0.85) 2.83 (0.97)

Alcohol consumption (>= 5 days/week) 2.82 2.23 3.93

Smokes at present time (%) 19.18 22.11 13.62

Obesity (BMI > 30) 23.79 19.22 32.44

IADL (range of 0-5) 0.25 (0.69) 0.16 (0.52) 0.43 (0.91)

Mobility (range of 0-4) 0.54 (0.97) 0.39 (0.79) 0.84 (1.19)

Number of remembered animals 19.03 (7.35) 21.30 (7.15) 14.76 (5.62)

Number of observations 1,100

Source SHARE data, 2nd

wave (2005-2006)

Other notable differences pertain to obesity, alcohol consumption and smoking. While

about 32 percent of immigrants are obese, only 19 percent of natives are. Immigrants

also score higher in alcohol consumption. However, a much smaller percentage of

immigrants (14 percent) smokes than natives (22 percent). The health profile of

immigrants to Israel is in congruence with previous studies that show that former USSR

immigrants have significantly higher BMI, lower reported “good” health status, higher

incidence of heart attack and other chronic diseases (Manoff et al., 2011).

Regarding demographics, immigrants have a larger percentage of men, and of being

married. They also have an older age structure (the majority is in the 61-70 age group).

On the other hand, they have fewer children and a lower household income.

Interestingly, about 66 percent of immigrants report having more than 12 years of

education, versus about only 48 percent of natives. Lastly, the majority of immigrants

have been in Israel for more than 11 years; 50 percent arrived in the 1990s.

Parallel summary statistics on these characteristics for the European sample are reported

in Table 2. Here, we have a very different picture. The SRH levels of immigrants are

slightly higher than those of natives. Overall, the native-immigrant differences seem to

indicate an immigrant health advantage, although the results are somewhat mixed.

Regarding being diagnosed with major diseases, number of medical symptoms,

prescription drug use, hospitalization, eyesight, and mobility immigrants are in better

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shape than natives. In addition, a smaller percentage of immigrants is obese (17 percent

versus 20 of natives) and consumes alcohol (18 versus 25). However, in some other few

aspects immigrants report an inferior health status as is shown by the annual number of

medical consultation and their cognitive skills. A larger percentage of immigrants smokes

(24 percent) than natives (19 percent). Differences in economic integration, host language

proficiency, and social barriers are likely factors why immigrants respond to the health

system differently than natives.

Table 2 Summary statistics, natives and immigrants in Europe

Characteristics Whole sample

Means (st.dev)


Means (st.dev)


Means (st.dev)

SRH (range of 1-5) 2.72 (1.05) 2.72 (1.05) 2.79 (1.08)

Years since migration (YSM) (%)

Up to 10 years since migration - - 10.59

11 –to- 20 years since migration - - 11.51

21 and over years since migration - - 77.90

Arrival years between

1900-1950 - - 17.26

1951-1960 - - 13.57

1961-1970 - - 21.40

1971-1980 - - 17.02

1981-1990 - - 10.29

1991-2000 - - 11.99

2000-2010 - - 8.47

Country Macros

Log. per capita GDP (host country) 10.46 (0.42) 10.46 (0.42) 10.46 (0.42)

Socio-economics and demographics

Male (%) 46.03 46.03 45.96

Age in years (%)

50-60 36.52 35.28 53.76

61-70 29.50 29.72 22.12

71-80 21.88 22.08 15.33

81+ 12.10 12.20 8.79

Marital status (%)

Married 66.54 66.53 66.62

Widowed 17.49 17.64 12.66

Single/divorced/separated 15.97 15.83 20.72

Number of children 2.10 (1.42) 2.10 (1.42) 2.24 (1.55)

Household income centile (1-10) 5.36 (2.94) 5.37 (2.94) 5.09 (2.98)

Education (more than 12 years) (in %) 29.25 29.21 30.55

Personal Medical variables Health conditions; diagnosed with..(%)

Heart problems 12.27 12.31 10.90

Hypertension 37.50 37.71 30.43

Cerebral vascular disease 3.36 3.39 2.26

Diabetes 12.87 12.83 13.97

Chronic lung disease 6.54 6.60 4.40

Arthritis 24.49 24.56 22.43

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Characteristics Whole sample

Means (st.dev)


Means (st.dev)


Means (st.dev)

Osteoporosis 2.58 2.59 2.04

Cancer 4.97 4.97 4.99

Number of medical symptoms 1.71 (1.78) 1.71 (1.78) 1.60 (1.69)

Drug use (number of drugs) 1.55 (1.65) 1.56 (1.66) 1.37 (1.60)

Medical consultation (annual-number) 7.41 (9.91) 7.42 (9.86) 7.60 (12.04)

Hospitalization (%) 15.79 15.89 12.27

Quality of eyesight (range of 1-5) 3.22 (1.00) 3.23 (1.00) 3.29 (0.97)

Alcohol consumption (>= 5 days/week) 25.05 25.26 18.17

Smokes at present time (%) 19.28 19.15 23.70

Obesity (BMI>30) 19.60 19.68 17.10

IADL (range of 0-5) 0.19 (0.70) 0.19 (0.70) 0.17 (0.66)

Mobility (range of 0-4) 0.58 (0.97) 0.58 (0.98) 0.51 (0.89)

Number of remembered animals 18.25 (7.80) 18.27 (7.82) 17.13 (6.78)

Country shares in the sample (%)

Austria 2.16 2.09 4.23

Germany 22.62 22.79 16.75

Sweden 2.33 2.37 0.73

The Netherlands 4.09 4.11 3.41

Spain 11.10 11.12 10.70

Italy 17.64 18.02 5.05

France 15.57 15.03 33.36

Denmark 1.45 1.48 0.40

Switzerland 1.95 1.77 7.65

Belgium 2.83 2.75 5.37

The Czech Republic 3.33 3.33 3.60

Poland 9.83 10.06 2.05

Hungary 2.18 2.20 1.56

Portugal 2.19 2.22 1.27

Slovenia 0.45 0.41 1.68

Estonia 0.27 0.22 2.17

Number of observations 59,079

Source SHARE data, 2nd

wave (2005-2006). The data include 16 European countries

On average, raw demographics in Table 2 show that immigrants and natives in Europe

are very similar vis-à-vis their socio-economic status. There are some differences in the

age categories, in which the majority of immigrants is in the 50 to 60 age group and in

years of education, with a higher percentage of immigrants having more than 12 years.9

We proceed with multivariate regression analysis to arrive at the net effects of the

immigration status (YSM) on SRH. We control for all health conditions, behavior, and

socio-economic status.

9 Based on the 2004 wave of SHARE and eleven European countries, and studying the differential health

system usage by immigrants and natives, Solé-Auró et al. (2012) find evidence of higher healthcare usage by immigrants, as a whole.

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SRH estimations: Israel versus European countries

The European sample contains 16 countries. Because individuals are clustered within

countries, we use random-effect multilevel analysis for the European regressions, which

is the most appropriate technique to analyze within-and between-country variation and

also allows the inclusion of macro-country variables. A careful analysis is conducted to

provide answers to our core question: are native-immigrant health disparities different in

Israel than in European countries. In particular, we test our core hypothesis that the

“healthy immigrant effect”, which is evidenced in many countries and presented in

numerous studies, will not be found in Israel.

Our dependent variable is the respondent’s subjective assessment of her/his health-status

(SRH), ranging from 1 (very poor) to 5 (excellent). The explanatory variables include

years-since-migration dummies (for migrant respondents), as well as a battery of health,

behavioral, demographic, and socio-economic variables. We use a non-linear form of

YSM because additional years of residence in the host country may have a differential

effect on health. YSM is thus a categorical variable with three levels: (i) less than 10

YSM; (ii) 11-20 YSM; (iii) more than 20 YSM. Natives are the reference group.

In the regression of the European sample we also include the country-level per-capita

GDP (log), in order to control for the host country development level (see Appendix

Table A1 for variable definitions). The samples are: SHARE 2nd

wave for Israel and

SHARE pooled sample of 2nd

and 4th

waves for Europe. For the Israeli sample we use

Ordinary Least Squared (OLS). For the European sample we use random-effects

multilevel regression analysis, because individuals are clustered within countries.

Regression results in Table 3 confirm a “sick immigrant effect” for Israel and a “healthy

immigrant effect” in Europe. Newly arrived immigrants are significantly less healthy than

Israeli natives, while they are significantly healthier than natives in European countries.

For Israel, the lower health status of immigrants upon arrival appears to persist and

remains significant for up to 20 YSM, after which time their health status is no different

than that of the natives.

The persistence of their lower health in Israel in spite of having immediate access to

health insurance and governmental support for schooling, housing, language, etc. could

be related to the stress of acculturation,10

acclimatization and fitting in as well as their

lower socioeconomic status. Moreover, immigrants, especially older ones, tend to

preserve their cooking and eating habits from the home country. Immigrants from the

former USSR countries, for example, are known to consume heavy food, rich in

cholesterol and saturated fat. Lack of their traditional foods in the host country, may

prompt them to consume more convenience food high in fat and sugar. Immigrants from

Africa may also suffer from nutritional inadequacies if they follow the poor diets of their


The debilitating effects of the stress of acculturation among immigrants in Israel from the former USSR

(compared to natives and other Jews in Russia who did not migrate) are evident in the Ritsner and

Ponizovsky (1999) study. These immigrants suffered by psychological distress and had psychosomatic


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In contrast, immigrants in Europe who arrive with better health than natives lose this

advantage within the first decade of YSM. Their health status is no different than that of

natives for 11 to 20 YSM and becomes positive and significant again after more than 20

YSM, albeit it is a small number close to zero. This result is in line with other studies

Popovic-Lipovac and Strasser (2015) explain the deterioration of the immigrant SRH

through a busier lifestyle in the host country, coupled with lack of social relations and

safety nets.

Table 3 Determinants of SRH, Israel versus Europe

Variables Israel Europe

(i) Immigrant status

Up to 10 years since migration -0.310***




11 to 20 years since migration -0.326***




21 or more years since migration -0.038




Natives Ref Ref (ii) Country variables

Log of country GDP per capita - 0.348***


(iii) Demographics

Age (years) 50-60 Ref. Ref.

61-70 -0.005




71-80 -0.080




Over 80 0.091




Male -0.093




Marital status




Married -0.029




Widowed 0.004




Number of children 0.066***




iv) Socio-economic variables

Household income centile 0.004




Education (more than 12 years) 0.135***




(v) Personal medical variables

Drug use -0.055***




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Variables Israel Europe

Health conditions-diagnosed with






Hypertension -0.100*




Cerebral vascular disease -0.180*




Diabetes -0.243***




Chronic lung disease -0.005




Arthritis -0.115




Osteoporosis -0.003




Cancer -0.194*




Number of medical symptoms -0.057***




Medical consultation (number) -0.007***




Hospitalization (dummy) -0.237***




Quality of eyesight (range of 1-5) 0.258***




Alcohol consumption 0.058




Smokes at present time -0.144*




Obesity (BMI>30) -0.213***




IADL -0.055




Mobility -0.118***




Cognitive skills: remembered animals 0.003




Year of interview dummies - Yes

Sample Size 1,100 59,079

AIC 2673 138202

BIC 2833 138553 Note Sample sizes are somewhat smaller than those used for the SRH distributions, due to missing values of part of the explanatory variables; the model is estimated with multilevel analysis Significance levels *** P\0.01; ** P\0.05; * P\0.1. Standard errors in parentheses

As expected, a higher GDP per capita in the host country is associated with a higher SRH

(in Europe). In the European sample we find a strong aging effect as well, even after we

control for all possible health characteristics. Men have lower SRH than women and

married individuals have lower SRH than the single/divorced/separated; widows have

higher SRH than the reference group. All these characteristics however, are not

significantly different than zero in the Israeli sample. In both samples, the higher number

of children is associated with higher SRH and so is more years of education.

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Another notable difference between the samples has to do with the household income,

which has a positive and significant effect on SRH in the European sample, but has no

effect for Israel. Turning to the medical variables, we see that those who use prescription

drugs have a significantly lower SRH. Similarly, those with a higher number of medical

symptoms and medical consultation as well as more hospitalizations have a lower SRH.

When it goes to the diagnosed medical conditions of individuals, there are differences

between the two samples. Only diabetes, hypertension and cancer significantly lower

SRH in the Israeli sample. In the European sample, all health conditions cause lower

SRH. While eyesight quality increases SRH in both samples, smoking, obesity, and

reduced mobility decrease SRH. Alcohol consumption has a detrimental effect on SRH

for the European sample only, but no effect in the Israeli sample. Finally, good cognitive

skills increase SRH in the European sample, but they have no effect in the Israeli sample.

Highlights and conclusion

This paper studies the self-reported health status of immigrants and natives comparing

sixteen European countries to Israel by employing the SHARE data base that provides

comparable data. Most of the previous literature finds a “healthy immigrant effect”

(HIE), meaning that immigrants have a higher health status than natives when they first

arrive in the host country and during their first years since migration (YSM), but their

health deteriorates with additional years of residence in the host country and approaches

that of natives. This phenomenon is attributed to the positive health self-selection of

migrants, the additional hurdles they have to overcome during their migration journey, in

which only the healthiest can survive and to the health screening or positive selection that

the host countries apply.

However, Israel is a country build on ideology and encourages the migration of Jews

from all around the world to the homeland without imposing any health restrictions.

Israel perceives this as a return home and not as migration. Moreover, Israel has assisted

Jews in undertaking the migration trip and provides immediate help and health insurance

to all upon arrival. We hypothesize that the healthy immigrant effect may not hold in the

Israeli case. To test this hypothesis we are employing the 2nd

wave of the SHARE data in

2006, which is the only wave that includes Israel. From Europe, we include sixteen

countries and compare the SRH health of immigrants and natives. All individuals in all

countries in SHARE were given the same questionnaire, which provides a smooth


Both raw statistics and regression results confirm that there are indeed differences in the

health status of immigrants when compared to natives between Israel and the European

countries. On average, immigrants to Israel are in the health status “fair” while natives

are in the health status “good” (a category above). Compared to natives, immigrants to

Israel have also been diagnosed with major diseases, have more medical symptoms and

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more mobility limitations, use more prescription drugs, have a higher number of

hospitalizations, have lower cognitive skills, and suffer more from eyesight problems. A

higher percentage of them is in the obese category. Multivariate analysis confirms that

immigrants to Israel fit into a “sick immigrant effect”, meaning that they arrive with a

lower health status than natives and this status persists for several decades even after we

control for all socioeconomic, demographic and medical characteristics. Our results are

validated by previous studies in the medical and epidemiological literature.

Comparable analysis using the European sample reveals a different picture. Overall,

immigrants to Europe are in a better health shape than natives. First, raw statistics show

that they are in the same category of SRH (“good”) as natives, albeit slightly higher. This

is supported by their profile vis-à-vis their diagnosed diseases, medical symptoms, drug

use and hospitalization. What stands out is that fewer immigrants than natives are obese,

and fewer consume alcohol. However, more of them smoke. While they have a younger

age structure, they have similar household incomes. Second, controlling for all other

characteristics, immigrants in Europe exhibit a “healthy immigrant effect”. Up to their

first ten YSM, they report a significantly healthier status than natives. This health

advantage disappears with additional years of living in the host country and they become

indistinguishable from natives.

Our results contribute to the literature on health assimilation between immigrants and

natives and selection, by providing a unique comparative study between countries with

totally different migration policies. Our results increase our understanding of the health

disparities between immigrants and natives and among different countries. We also

enrich our study with the use of multilevel techniques and distinctive health,

demographic and socio-economic variables. We provide evidence that self-selection

alone does not explain the healthy immigrant effect. The migration journey, whether it is

assisted and cushioned by the host country or not, plays also a role. Above all, we show

that the migration policies of the host countries have a lot to do with the health quality the

migrants receive. Israel being a unique example in this respect, has been receiving

immigrants who have poorer health than natives and this inferiority is long-lasting.


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Table A1 Description of variables

Demographic variables

Age Four dummy variables, relating to the age groups of: 61-to-70; 71-

to-80; 81-to-90; 91 and over; with the reference group being age of


Gender Dummy variable that is set to 1 for male respondents.

Marital status Two dummy variables: married and widowed, with the reference

group including: divorced, separated and single.

Number of


Number of the respondent’s children.

Socio-economic variables


income centile

Respondents’ household income centiles.

Education Dummy variable that equals 1 if the respondent has at least 13 years

of schooling.

Medically based health

Drug use Continuous variable that is the number of different drugs that the

respondent takes at least once a week (e.g., drugs for high-

cholesterol, high blood-pressure, joint pain, back pain, sleep

problems, anxiety or depression, stomach burns).



Set of dummy variables that relate to diseases that the individual was

diagnosed with. They include: heart diseases; hypertension; vascular

diseases; diabetes; lung diseases; arthritis; osteoporosis; and cancer.

Health symptoms Continuous variable that is the sum of different symptoms that the

individual suffered from during the last 6 months (e.g., sleeping

problems, falling down, persistent cough, fatigue, swollen leg,




Continuous variable that is the response to the question: “During the

last 12 months, about how many times in total have you seen or

talked to a medical doctor about your health. Please exclude dentist

visits and hospital stays, but include emergency rooms and

outpatient clinic visits”.

Hospitalization Dummy variable that equals 1 if the respondent answered positively

the question: “During the last 12 months, have you been in hospital

overnight? Please consider stays in medical, surgical, psychiatric or

any other specialized wards.”

Quality of


Continuous variable ranging from 1 (poor) to 5 (excellent). It is the

average of 2 variables related to eyesight that are the responses to

the question: “Your distance/reading eyesight is: poor (1)…excellent


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Behavioral risk factors



Dummy variable is defined: it equals 1 if the respondent, during

the last 3 months, uses to drink any alcoholic beverages, like

beer, wine, spirits or cocktails at least 5 days a week.

Obesity Dummy variable that is equal to 1 if the Body Mass Index

(BMI, based on weight and height) is greater than 30.

Smokes at

present time

Dummy variable that is set to 1 for respondents who smoke at

the time of the survey.

Functional capacity

IADL Number of limitations with several instrumental activities:

preparing a hot meal, shopping for groceries, making telephone

calls, taking medications, and managing money (such as paying

bills). The IADL index ranges from 0 – 5

Mobility Describe the functional capacity of the individual, indicated by:

walking 100 meters, walking across a room, climbing several

flights of stairs, and climbing one flight of stairs. Mobility is an

index in the range of 0 – 4

Cognitive abilities



Continuous variable that is the number of animals that the

individual listed in 60 seconds, in response to the question: “I

would like you to name as many different animals as you can

think of. You have one minute to do this.”